Better, sooner, more convenient health care in Midlands

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4 The Integrated Family Health CentreA local focus on taking control of the dayFlow Team servicing both mobile and in-situ teamWho they are:• Patient Advocate role• Medical PA for all General Practitioners• Patient Flow WorkersWhy they exist:Focused on patient satisfaction, patient engagement and maintaining a complete baseline recordof the patient’s health record. The Flow Team is a dedicated amount of resource that is focused onkeeping the day moving according to a team plan. They are the conduit or fulcrum between thein-situ and the community team. Their core mission is to keep the largest possible proportion of theirenrolled population engaged.Engaged High Needs Non- EngagedManage pre visit planningReview workflow and plan accordinglyCoordinate patient centred careAnswer patient phone-callsMake follow up contactUpdate patient records post and previsitManage call backsManage regular check up apptmentsManage patient health milestonesMeet & greet - provide pre visitscreeningLiaise with referral centreOversee IT and admin systemsAllocate walk in capacityCoordinate team work in progressManage patient expectationsOrganising General Practitioneravailability for case conferencingEnsuring General Practitioner availabilityfor case conferencesEnsuring General Practitioner availabilityfor triage situations from communityteamsLocate non-engaged patientsManage interface between communityand in-situ careStakeholder management andengagementHold key community relationshipsKeeping community team up to dateFlag alerts needing particular attentionor sensitivityFlag inter-agency visiting on complexcasesHelp access to fund solutions to barriersfor engagement (childcare, travel etc)What they do:A Health Care Team working in the community but based at theIntegrated Family Health CentreWho they are:• Mobile Nurse team (Healthright Nurse, District Nurse, Public Health Nurse)• Health Coach• Kaiawhina/ Patient LiaisonWhy they exist:Patients often prefer, for a variety of reasons, to receive their care in the community. A team thatcomes to a patient’s home or another more neutral setting in the community can often overcomebarriers to access that can be seen as overwhelming in an in-situ setting. This team provides timeframed,coordinated General Practitioner lead care and ensures a more wrap around service for thepatient and their family.A team may be based in an area specific to the Integrated Family Health Centre population thatrequires significant support (Older Persons), a geographic location or community, a cultural or hapubased group or a specific ethnic community.43
The Integrated Family Health CentreA local focus on taking control of the day4What they do:Non-engagedDischarge from HospitalSupport required to work towardsself-managementLocateVisitWork with communityWork with family/whanauNo wrong doorLiaise with other community agenciesCoordinate complex case approachFocus on not overwhelming familyIncrease circle of indirect monitoring forU5s and over 65sEnsure patients are comfortable withdischarge instructionsVisit patient in hospital to plan at homecareSupport and advise familyCoordinate access/supportEnsure prescriptions are filledEstablish self-management plansEnsure patient understands instructionsto achieve self-managementReview self-management planProvide clinical assistance whererequiredCoordinate services where requiredLiaise with General Practitioner in orderto deliver appropriate careTime-framed regular care for chronicconditionsProvide education/support/guidance ingroup based situations specific to theneeds of the communityClip ons - customising with the optional extrasEach enrolled population brings with it it’s own specific elements and subtleties. Some communitiesmay have cultural or ethnic commonalities while others may share an age band spectrum orgeographical region.While every Integrated Family Health Centre will have its own base set of mandatory components, aseries of Centre Specific clip ons are available according to need, want, relationship or patient focus.The opportunity exists, where there is space and energy, for other non-clinical clip ons to be addedthat may serve to add further synergies or levels of convenience for an enrolled patient base. Suchelements should be considered as a part of the planning process wherever an Integrated FamilyHealth Centre is established and appropriate community decisions made at the time.Clinical / Allied Commercial Non-clinicalPhysiotherapyPodiatryDiabetic PodiatryOccupational TherapyNaturopath ServicesAccupunctureCounsellorsRongoaMirimiriDentistSpecialistsElective SurgeryMole MappingDietitiansNutritionistMassageCafeBeauty TherapyGymNatural HealthAlternative TherapiesHairdressersYoga/Pilates StudioRest HomeCACI ClinicsDaycareLarge scale employerWork & Income Case WorkersHeartland CentreChild, Youth & FamilyAge ConcernPromoting ParticipationStudyLink44
Page 5: MihimihiKo te amorangi ki muaKo te
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Delivering on health targets7Needs
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Letters of Support10126
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Better, sooner, more convenient health care in Midlands

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